To help ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis, Anthem Blue Cross and Blue Shield reviews clinical information – including lab results, treatment and medical management – in the medical records submitted.  In order to conduct the review accurately and consistently, our review process for the sepsis diagnosis applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in the Journal of the American Medical Association (JAMA) February 2016. 

Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patients’ clinical course supports the coding and billing of a diagnosis of sepsis.  The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria.

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June 2019 Anthem Provider Newsletter - Virginia